Thursday

That aspirin a day to prevent heart disease? You might need to put it away.

The American College of Cardiology and the American Heart Association revised their joint guidelines in March.

For decades, doctors had recommended a low-dose aspirin to prevent atherosclerotic cardiovascular disease (certain types of heart attacks and disease and strokes).

“In the old days, we said everyone over 50 should take an aspirin,” says Dr. Paul Tucker, a cardiologist at St. David’s South Austin Medical Center in Austin, Texas.

The new recommendations tell doctors to not give it to patients who are 70 and older for prevention unless they fall into a select group of people who have already had a heart attack, stroke or similar incident or who have elevated risk factors. It should be avoided in any person who has a high risk for bleeding.

The problem is that the risk for bleeding was outweighing the benefit of prevention.

A study in September that looked at 19,000 people age 70 or older who were either given aspirin or a placebo found no difference in the rates of disability, dementia or death. What researchers did find was an increased risk of bleeding.

What does this mean for people who have been taking aspirin to prevent a heart attack or stroke?

Ask your doctor, Tucker says. “I still think it’s up to doctors and their patients,” he says.

The biggest risk with aspirin is bleeding from the gastrointestinal tract. That typically shows up as a change in stool color (it looks black or much darker) or there is nausea or throwing up blood or something that looks like coffee grounds.

“It’s still very uncommon,” Tucker says.

What he and other cardiologists have to do is look at each individual patient and weigh that patient’s risk of bleeding versus the risk of heart attack. Or it might be that in some patients it’s not a “no-aspirin-at-all but a less-aspirin” recommendation, such as a baby aspirin twice a week or three times a week to inhibit the platelets but not cause the bleeding.

“This is the art of medicine, rather than the science,” he says. He might tell his patients, “I know about the guidelines, but you’re really at high risk for a heart attack and you’ve never had stomach bleeding.”

Instead he’ll look at their risk factors including diabetes, smoking, obesity, genetics, cholesterol, blood pressure and the calcium score of the coronary artery. There’s a calculator doctors use to assess the risk.

Then he might choose other therapies to control elevated cholesterol, blood pressure or blood sugar, or if the patient is really at high risk, he might continue the aspirin.

“Guidelines are important,” he says, “but individual patient characteristics need to be discussed.”